Understanding Leukoplakia

Definition (WHO):

“A white patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease.”

Key Characteristics:

• Appearance: White या greyish-white patch
• Cannot be removed: Cotton swab/tongue blade से पोंछने पर नहीं हटता (यह बहुत important distinguishing feature है)
• Asymptomatic usually: ज्यादातर cases में कोई दर्द/जलन नहीं – accidentally discover होता है
• Any oral site: कहीं भी हो सकता है – buccal mucosa (गाल), tongue, floor of mouth, palate, lips
• Variable size: Small spot से लेकर large area तक

Local Understanding – लोग कैसे Describe करते हैं:

• “Muh ke andar safed daag hai”
• “Gaal par white patch ho gaya hai”
• “Jeebh par safed-safed ho gaya”
• “Yeh pochne se nahi jata”
• Sometimes: “Khurdura lag raha hai” (rough)

Types of Leukoplakia

1. Homogeneous Leukoplakia (70-80%)

Appearance:

• Uniformly white
• Flat या slightly raised
• Smooth या slightly wrinkled surface
• Well-defined borders

Malignant Potential: Lower (3-5%)

2. Non-Homogeneous Leukoplakia (20-30%) – MORE DANGEROUS

Subtypes:

A. Erythroleukoplakia (Speckled)

• White patches MIXED with red areas
• Red = erythema (inflammation/increased vascularity)
• ⚠️ High malignant potential: 15-30%

B. Nodular Leukoplakia

• Small white/red nodules
• Rough, granular surface
• High-risk

C. Verrucous (Warty)

• Thick, irregular surface
• Looks like cauliflower
• Usually on buccal mucosa या gingiva
• Can become verrucous carcinoma

3. Proliferative Verrucous Leukoplakia (PVL) – MOST AGGRESSIVE

• Rare but very serious
• Multifocal (multiple sites)
• Progressive
• Resists treatment
• 70-100% malignant transformation rate!
• More common in elderly women, non-smokers (idiopathic)

Causes & Risk Factors

1. Tobacco – SINGLE BIGGEST CAUSE (80-90%)

A. Smokeless Tobacco (Chewing) – MOST RELEVANT in Hardoi/UP

Forms:

• Gutka/Paan Masala: Commercial sachets – highest risk
• Khaini: Tobacco + lime
• Zarda: Flavored tobacco
• Betel quid with tobacco: Traditional paan
• Gudakhu: Powdered tobacco

Mechanism:

• Direct contact with oral mucosa
• Carcinogens (nitrosamines) in tobacco
• Chronic irritation
• Keeps in one place (बार-बार same spot पर रखते हैं) → localized effect
• Years of use → cellular changes → leukoplakia → dysplasia → cancer

Pattern:

• Leukoplakia होता है जहां tobacco रखते हैं
• Usually: Lower labial/buccal sulcus (cheek and lower lip के बीच)
• If bilateral → usually both sides में tobacco rखते हैं

B. Smoking Tobacco (Bidi, Cigarette, Hookah)

• Also causes leukoplakia but less site-specific
• More generalized oral mucosal changes
• Palate involvement common (nicotinic stomatitis)

C. Reverse Smoking (चुट्टा)

• Lit end INSIDE mouth (practiced in some parts of India)
• Very high-risk for palatal leukoplakia and cancer

2. Alcohol

• Independent risk factor
• Synergistic with tobacco → risk multiplies 30-40x if both!
• Alcohol = solvent → helps carcinogens penetrate mucosa

3. Chronic Mechanical Irritation

• Sharp tooth edge: Broken/jagged tooth constantly rubbing
• Ill-fitting dentures: Chronic friction
• Cheek biting habit: Repeated trauma
• These cause “frictional keratosis” which can look like leukoplakia

4. Viral (HPV – Human Papillomavirus)

• Especially HPV 16, 18 (same as cervical cancer)
• Oral sex transmission
• Increasing incidence in young, non-tobacco users

5. Candida (Fungal) Infection

• Chronic candidiasis can cause chronic hyperplastic candidiasis
• Looks like leukoplakia but is fungal
• More common in immunocompromised, diabetes

6. Idiopathic (Unknown)

• 10-20% cases – no identifiable cause
• May have genetic predisposition

Clinical Presentation – कैसे दिखता है?

Typical Patient Profile:

• Age: Usually >40 years
• Gender: Males > Females (because tobacco use higher in males)
• Occupation: Any, but agricultural workers, laborers (higher tobacco use)
• Tobacco history: 80-90% have significant history

Symptoms:

Usually Asymptomatic (60-70%)

• No pain, no discomfort
• Patient या family member notices white patch
• या dentist discovers during routine exam

If Symptomatic:

• Burning sensation (10-20%): Especially with spicy food
• Rough feeling: “Khurdura lag raha hai”
• Altered taste: If on tongue
• Pain: RARE unless ulceration (worrisome sign!)

Sites of Occurrence (Frequency):

1. Buccal Mucosa (40-50%): Inside of cheeks – most common
2. Tongue (25-30%):
   • Lateral borders (sides) – HIGH RISK AREA
   • Ventral surface (undersurface)
   • Dorsum (top)
3. Floor of Mouth (10-15%): HIGH RISK AREA for malignant transformation
4. Lips (10%): Usually lower lip
5. Palate (5-10%): Hard palate mostly
6. Gingiva (Gums) (5%):

⚠️ High-Risk Sites: Tongue (especially lateral/ventral), Floor of mouth, Soft palate – leukoplakia यहां होने पर malignant transformation ज्यादा होता है।

Differential Diagnosis – Leukoplakia से मिलते-जुलते Conditions

बहुत important – हर सफेद patch = leukoplakia नहीं!

1. Oral Candidiasis (Thrush) – MOST COMMON MIMIC

Differentiation:

• Appearance: White curd-like patches
• KEY: Can be WIPED OFF! Underneath = red, raw mucosa (bleeding)
• Leukoplakia wiping से नहीं हटता
• Symptoms: Burning, bad taste
• Risk factors: Diabetes, antibiotics use, immunocompromised, denture wearers
• Diagnosis: KOH mount/culture shows fungal hyphae
• Treatment: Antifungal (fluconazole) – resolves completely

2. Oral Lichen Planus

• Appearance: White lacy/reticular pattern (network of white lines)
• Bilateral (both sides usually)
• Symmetrical
• Buccal mucosa most common
• Symptoms: May have erosions (painful)
• Cause: Autoimmune
• Malignant potential: Low (1-2%) but needs monitoring
• Biopsy: Shows characteristic histology

3. Frictional Keratosis

• Due to chronic mechanical irritation
• White thickening along line of trauma
• KEY: Resolves when irritant removed! (sharp tooth smoothed, denture adjusted)
• Leukoplakia persists even after stopping tobacco

4. White Sponge Nevus

• Benign hereditary condition
• Present from childhood/adolescence
• Bilateral, thick white folds
• No malignant potential

5. Chemical Burns

• Aspirin burn: Patient places aspirin against tooth for toothache → white sloughing
• History important
• Heals in few days

Diagnosis at Prime ENT Center

1. Clinical Examination

Dr. Harshita Singh / Dr. Prateek Porwal will:

• History:
  • Tobacco/alcohol use (detailed – type, duration, frequency)
  • कब notice किया?
  • Size में change हो रहा है?
  • Any symptoms?
• Inspection:
  • Location, size, number
  • Color (homogeneous white या mixed red-white?)
  • Surface texture (smooth, rough, nodular?)
  • Borders (well-defined या irregular?)
  • Try to wipe – does it come off? (rule out candidiasis)
• Palpation:
  • Soft या indurated (hard)?
  • Induration = worrisome (suggests deeper involvement)
• Complete Oral Cavity Examination:
  • Check for other lesions
  • Neck lymph nodes (any enlargement?)

2. Biopsy – GOLD STANDARD & ESSENTIAL

⚠️ Every leukoplakia MUST be biopsied!

Why:

• Confirm diagnosis (rule out other white lesions)
• Most Important: Detect dysplasia (pre-cancerous changes)
• Grade severity
• Rule out malignancy (already cancer)

Procedure:

• Local anesthesia
• Small piece of tissue (including normal margin) removed
• OPD procedure usually
• Sent for histopathology
• Report in 5-7 days

What Biopsy Shows:

Histopathology Findings:

• Hyperkeratosis: Thickened keratin layer (gives white color)
• Acanthosis: Thickening of epithelium
• +/- Dysplasia: Abnormal cellular changes (MOST IMPORTANT!)

Dysplasia Grading:

No Dysplasia:

• Just hyperkeratosis, no abnormal cells
• Malignant risk: Low (1-3%)
• But still needs monitoring

Mild Dysplasia:

• Architectural changes in lower 1/3 of epithelium
• Risk: 5-10%

Moderate Dysplasia:

• Changes extend to middle 1/3
• Risk: 10-30%

Severe Dysplasia:

• Full thickness changes
• Risk: 30-50%
• Urgent treatment needed!

Carcinoma in Situ:

• Entire epithelium dysplastic but basement membrane intact
• Essentially cancer that hasn’t invaded yet
• 100% will become invasive cancer if untreated

Invasive Squamous Cell Carcinoma:

• Already cancer
• Needs oncology referral

3. Additional Tests (If Indicated)

• Toluidine Blue Staining: Highlights dysplastic areas for biopsy site selection
• Brush Biopsy: Non-invasive screening, but confirmatory biopsy still needed
• Imaging (CT/MRI): If invasion suspected

Treatment at Prime ENT Center

Treatment Depends on Dysplasia Grade:

For Leukoplakia WITHOUT Dysplasia या Mild Dysplasia:

Step 1: ELIMINATE CAUSATIVE FACTORS – ESSENTIAL!

Stop Tobacco/Alcohol:

• Complete cessation – non-negotiable!
• Even mild dysplasia can progress if habit continues
• 25-40% lesions REGRESS (disappear) after stopping tobacco!
• Counseling, de-addiction support at Prime ENT

Remove Irritants:

• Sharp teeth smoothed
• Ill-fitting dentures adjusted
• Stop cheek biting habit

Step 2: Observation (Watch & Wait)

• Regular follow-up: Every 3-6 months
• Clinical examination each visit
• Document with photos
• Re-biopsy if:
  • Lesion increases in size
  • Appearance changes (becomes red, nodular)
  • Develops ulceration
  • New symptoms (pain)

Step 3: Medical Management (Experimental)

• Vitamin A derivatives (Retinoids): Some studies show benefit
• Beta-carotene: Antioxidant
• Not standard of care, variable results

For Moderate/Severe Dysplasia या Non-Homogeneous Leukoplakia:

Surgical Excision – RECOMMENDED

Why:

• High malignant potential
• Observation not safe
• Complete removal prevents progression

Methods:

• Scalpel Excision:
  • Traditional surgical removal
  • With margins (surrounding normal tissue included)
  • Sent for histopath to ensure complete excision
• Laser Ablation:
  • CO2 laser
  • Vaporizes lesion
  • Minimal bleeding
  • Good for large/multifocal lesions
  • But – no tissue for histology!
• Cryotherapy:
  • Freezing with liquid nitrogen
  • Less commonly used

Post-Surgery:

• Healing in 2-3 weeks
• Soft diet initially
• Lifelong follow-up ESSENTIAL (recurrence possible)

For Carcinoma in Situ या Invasive Cancer:

• Referral to Head & Neck Oncologist
• Wide excision +/- neck dissection
• Radiation therapy
• Chemotherapy if advanced

Prognosis & Malignant Transformation

Overall Malignant Transformation Rate: 5-25%

Factors Increasing Risk:

1. Clinical Features:

• Non-homogeneous type (especially erythroleukoplakia) >> homogeneous
• Size >200mm²
• High-risk site: Tongue lateral/ventral, floor of mouth
• Female gender (idiopathic leukoplakia in females – higher risk)
• Non-smokers (idiopathic cases – paradoxically higher risk)

2. Histopathology:

• Dysplasia presence & grade (most important predictor!)
• Candida presence (chronic hyperplastic candidiasis)

3. Continued Tobacco/Alcohol Use:

• Transformation rate doubles-triples if habit continues

Time to Transformation:

• Variable – months to years
• Average: 4-5 years
• Can be rapid (within 1 year) in high-grade dysplasia

If Tobacco Stopped:

• 25-40% complete regression
• Transformation risk significantly reduced
• But lifelong monitoring still needed

Prevention

Primary Prevention:

• Never start tobacco/alcohol!
• Public awareness campaigns
• School/college education programs

Secondary Prevention (Early Detection):

• Self-examination: Monthly oral cavity check in mirror
• Regular dental checkups: Dentist can detect early
• High-risk individuals: Annual ENT/oral surgeon exam
• Any white patch >2 weeks: Get evaluated!

Tertiary Prevention (Prevent Progression):

• Stop tobacco immediately after diagnosis
• Regular follow-up
• Timely treatment